Attention Deficit Disorder is now two or three times more common than it was just twenty years ago. A recent study reported that a whopping 10% of kids in the general population would qualify for the diagnosis. There has also been an incredible explosion in the use of medication in treating it.

What is going on? Are our kids rapidly getting much sicker? Or are we getting better at identifying ADD? Or is the diagnosis being spread around too loosely? Or is it some combination of all of the above and perhaps some other factors as well? This mystery cries out for solution, but yields no easy answers.

I can think of at least twelve different, probably interacting factors that may have contributed (in greater or lesser degrees) to the huge jump in ADD rates. These are not listed in any presumed order of priority because I am simply not sure how much weight to give to each.

1. Rates are now higher because our better diagnostic tools and increased awareness allow us to properly identify previously missed cases of true ADD.

2. The changes introduced by the DSM IV criteria made ADD diagnosis loose by lowering the definitional thresholds.

3. Kids previously diagnosed with Conduct Disorder are now often given an ADD label.

4. Massive direct-to-the-consumer drug company advertising to patients, parents, and teachers has succeeded in elevating ADD to fad status. Drug companies also used thought leader influence on and aggressive marketing to psychiatrists, pediatricians, primary care physicians, and other mental health workers to spread the gospel of ADD.

5. The increase in ADD symptoms results from environmental factors - like kids now being bombarded by an information overload driven by the internet or by drug use or by food additives or environmental toxins. 

6. The increased rate of ADD symptoms may be partly due prenatal problems like increased rates of premature birth and maternal drug use.

7. ADD is overdiagnosed because of increased perfectionism among parents and teachers who expect more self control from kids than is feasible given their developmental stage. 

8. We have less tolerance for what should be expectable and acceptable individual difference in activity levels and inability to focus and control impulses.

9. There has been a decrease in tolerance for ADD symptoms because parents are often single, stressed, and overworked and teachers are confronting large and unruly classes.

10. Enormous publicity generated by the media, the internet, and consumer advocacy groups has increased the visibility, popularity, and acceptability of ADD.

11. Schools require a diagnosis of ADD as a precondition for providing special educational services.

12. Epidemiological studies have relied on an inherently flawed methodology that results in inflated reported prevalences.

Unfortunately, there is no precise way to determine what should be the true rate of ADD and how influential each of these factors has been in contributing to the doubling or tripling the reported rates. Symptoms of ADD are so nonspecific and common in the general population, there is no bright line boundary separating the normal high spirited child from the psychiatrically ill one - and it's an inherently imprecise judgment that is very much in the eye of the beholder.

But we can make some guesses. The DSM IV field trials predicted that our changes would contribute only a 15% increase beyond the DSM IIIR rates. So DSM IV is probably responsible for only about one tenth of the meteoric rise in ADD rates.

The heaviest contributor by far is almost surely the clever, ubiquitous, and enormously expensive drug marketing campaign. During our work on DSM IV (published in 1994) and for several years later, the only drugs available for ADD had long been off patent and were available in inexpensive generic form. Not being very profitable for their makers, the old, standard medications were not actively marketed. Then the newly patented, expensive drugs appeared, provisioned with lavish marketing budgets. Coincidentally, this was also the very moment that drug companies were first permitted by their regulators to advertise directly to consumers on TV, print, and other media. There was an enormous ADD advertising blitz successfully attracting the attention of parents, patients, and teachers to the likelihood that a variety of troubling symptoms and behaviors could be accounted for by ADD and treated with a pill. Simultaneously there was a marketing blitz directed to doctors and mental health workers, cheered on by the expert thought leaders in the field. The drug companies cleverly realized that the best way to sell the new pills was to "educate" everyone about the unrecognized ubiquity of the ill.

The milder form of ADD has no clear boundary separating it from average expectable hyperactivity, impulsivity, and distractibility. There are wide individual differences in normal distribution of these features and also widely varying family, school, and cultural levels of tolerance. While some of the increase undoubtedly reflects better case finding, my guess is that aggressive drug company marketing has resulted in a great deal of excessive diagnosis- playing the lead role in provoking the epidemic. The media, internet, and consumer groups have been important supporting players.

ADD rates have also been exaggerated by the careless interpretation and reporting of the results of epidemiological studies. Because of the large cost of evaluating large samples, epidemiological studies necessarily use lay interviewers whose questioning on ADD symptoms is brief, superficial, and does not depart from a set script. Anything resembling a positive response to a question is scored as a symptom hit with no considered judgment of its context or clinical significance. Rates derived using such a superficial and nonclinical screening instrument can provide no more than an upper limit of true ADD rates. Determining likely rates of clinically significant ADD would require a second step with more detailed evaluation that includes context and clinical significance. Rates reported from recent epidemiological studies are likely to be double rates of real clinical disorder.

It is impossible to judge how much of the epidemic is influenced by parents and teachers having less time and patience for their unruly kids. Or by the fact that authorization for special services requires there be an ADD diagnosis? I think these are sometimes quite important, but overall much less a factor than the huge drug company push.

And, finally, how much of the reported increase might actually be due to a true rise of ADD symptoms in our kids - whether it be due to prenatal factors, or drugs, or other environmental toxins, or to the effects of the internet information overload or to social or parental dysfunction? Your guess is as good as mine. Mine is not much.

There is one way to begin sorting out this conundrum and come closer to understanding what is the best estimate of the rate of clinically significant ADD. A Dutch psychologist, Laura Batstra, has developed an innovative stepped diagnosis approach to the evaluation of ADD. The steps include collecting baseline data, normalizing the symptoms, watchful waiting, and parent and teacher training. The diagnosis is then reserved only for those kids who cannot be adequately managed within the prior steps and who therefore require further specific ADD treatment. This seems an altogether sensible and very cost effective way to weed out false positives and thus avoid unnecessary treatment and stigma.

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